Provider Demographics
NPI:1043596802
Name:DIAZ, MARANDA (CPNP)
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:MARANDA
Other - Middle Name:
Other - Last Name:MOLINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-4007
Practice Address - Fax:682-885-4004
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX694571363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics